Abnormal Vaginal Bleeding

Abnormal vaginal bleeding has many possible causes. By itself, it is not necessarily an indication of a serious condition: for example, ovulation can cause light spotting during the menstrual mid-cycle or there can be some minor bleeding between periods when starting the birth control pill or after an IUD is placed.  However, because abnormal bleeding can be serious, it always needs prompt attention.

Most commonly, abnormal vaginal bleeding originates from the uterus, or more specifically, from the lining of the uterine cavity, or the endometrium. Causes of uterine abnormal bleeding include uterine polyps (typically benign growths that arise from the endometrium), fibroids (benign tumors of the uterine muscle), adenomyosis (when endometrial glands embed in the uterine muscle), endometritis (infection or inflammation of the endometrium), endometrial hyperplasia (benign abnormal thickening of the endometrium), and, more unusually, uterine cancer. Abnormal vaginal bleeding from the uterus can also result from hormone changes, especially in women whose periods are just starting or almost ending, women with thyroid disease, and those with polycystic ovarian syndrome (PCOS). Abnormal vaginal bleeding can be cervical or vaginal in origin, such as from cervical infections, polyps, and cancer, or from vaginal thinning (atrophy), during menopause and vaginal infections.

The evaluation of a woman with abnormal vaginal bleeding begins with a thorough medical history. It should reveal information about menstrual bleeding patterns, bleeding severity, any associated pelvic pain, medications or herbal remedies that might cause bleeding, and any family history of abnormal vaginal bleeding or bleeding problems in general (because up to 20% of women who present with heavy periods are found to have an underlying bleeding disorder).

A general physical exam is then done as there may be findings related to the cause of abnormal vaginal bleeding. In a premenopausal woman, there may be signs suggestive of a hormonal imbalance, such as hirsutism and acne (both consistent with PCOS) or an enlarged thyroid gland or a thyroid nodule (consistent with thyroid disease). In a woman of any age, the finding of skin pallor or bruising may be a sign of a bleeding disorder, or the finding of an enlarged lymph node may be a sign of a gynecologic infection or cancer.

Following the general physical exam, a gynecologic exam is performed, which includes both a speculum and bimanual pelvic exam.  The speculum exam allows the visualization of the cervix and vagina so they can be inspected for any growths, polyps, ulcers, or signs of infection, such as vaginal discharge. The bimanual pelvic exam allows determination of the size and contour of the uterus and helps detect any uterine fibroids or ovarian or pelvic masses.

If there is suspicion that the uterus (or much less commonly, the ovary) is the source of the vaginal bleeding, then radiologic imaging is obtained for additional evaluation. The primary imaging test for abnormal vaginal bleeding is pelvic ultrasonography, or the pelvic sonogram.  The pelvic sonogram is performed both transvaginally (TV) and transabdominally (TA) for the most accuracy.

The TV/TA pelvic sonogram assesses the uterus for any abnormal enlargement (particularly if from fibroids), the endometrium for abnormal thickness or contour, and the uterine cavity for the presence of fluid. The pelvic sonogram also evaluates the ovaries for any cysts or masses and the fallopian tubes for any swelling. Any of these sonographic findings may be the cause of abnormal vaginal bleeding.  With regard to the endometrium in premenopausal women, its thickness normally varies throughout the menstrual cycle, so the pelvic sonogram is less useful in detecting abnormal endometrial thickening in these women. However, for postmenopausal women, whose endometrium should be thin, the pelvic sonogram is much more useful when it finds an abnormally thickened endometrium, which can be pathologic.

If the endometrium is abnormal on a pelvic sonogram, then an office endometrial biopsy, or sampling, is performed to look for pathology under the microscope. As mentioned above, endometrial pathology can range from endometritis to pre-cancerous or cancerous lesions. An endometrial biopsy on its own, however, may not always reveal the entirety of the pathology present in the endometrium. For further clarification, a special pelvic sonogram known as the sonohysterogram or an office hysteroscopy may be needed.

For a sonohysterogram, a small volume of salt water (saline) is instilled by a radiologist into the uterine cavity to expand it and separate its walls before a sonogram is done.  The fluid in the uterine cavity allows for a more detailed sonographic image of the endometrium, and it gives the radiologist a better idea of what endometrial abnormality may be present.  The information from a sonohysterogram together with the results of an endometrial biopsy can help determine the cause of abnormal uterine bleeding.

Beyond the sonohysterogram, office hysteroscopy provides the most information about what pathology may be present in the uterine cavity and is rapidly becoming the standard of care in the work-up for abnormal uterine bleeding. Using the EndoseeR  Advance System (see section on Office Hysteroscopy/Endometrial Biopsy using the EndoseeR) system—a safe, minimally-invasive office procedure—the inside of the uterus is directly visualized by the gynecologist through a scope with an attached camera.  Localized lesions, such as polyps, fibroids, or even cancers, can be seen and directly biopsied. These findings might then prompt going to the operating room for definitive surgical removal.

Finally, evaluation of abnormal vaginal bleeding requires laboratory assessment as well.  This includes blood work that evaluates for pregnancy, anemia or low platelet count, hormone levels, and tumor markers.